History of Physical Therapy PDF

PT 101 Module 4: History of In 1921, the creation of the Physical Therapy, Professional American Women's Physical Therapeutic Associ...

PT 101 Module 4: History of In 1921, the creation of the Physical Therapy, Professional American Women's Physical Therapeutic Association with Mary Roles and Characteristics of McMillan as the first president Physical Therapists In 1922, the organization was renamed the American ORIGINS OF PHYSICAL THERAPY Physiotherapy Association (APA) Ancient practices of physical therapy can be traced back to: IMPACT OF WORLD WAR II AND ○ Ancient Egypt, where POLIO massage and manipulation - World War Il further intensified the were used for healing. need for physical therapy services ○ Ancient Greece, with due to the high number of injured Hippocrates advocating for soldiers exercise and physical - The polio epidemic during this time activity. led to a significant increase in The formal establishment of patients requiring rehabilitation. physical therapy as a profession - Physical therapists became began in the late 19th century. essential in helping polio survivors The first physical therapy school regain mobility and independence. was founded in 1913 in the United States. POST WORLD WAR II PERIOD - PTs played key roles in polio IMPACT OF WORLD WAR I AND POLIO treatment trials (gamma globulin World War I led to a significant and Salk vaccine) starting in 1951. increase in the need for - The APTA was renamed in 1947, rehabilitation services. and its journal became Physical Many soldiers returned with injuries Therapy in 1962. requiring extensive rehabilitation. Women were trained as aides to 1960S THROUGH 1980S provide physical reconstruction for - The 1960s brought a focus on injured soldiers, marking the research and evidence-based beginning of physical therapy as a practice in physical therapy profession in the U.S. - The American Board of Physical Physical therapists played a crucial Therapy Specialties was created in role in rehabilitation, helping 1978 to certify clinical specialists. patients regain strength and - The Foundation for Physical mobility Therapy was established in 1979 to support PT research POST WORLD WAR I PERIOD 1990s After World War I, the focus of - The 1990s saw the introduction of physical therapy shifted from managed care and changes in military to civilian needs, healthcare policies affecting particularly for "crippled children" in physical therapy. industrial society  - Emphasis on cost-effectiveness and physical therapists practicing in the outcomes in physical therapy country services. - The Guide to Physical Therapist JUNE 21, 1969 Practice (1995) and Hooked on - With the other rehabilitation Evidence promoted research and professional groups, the PPTA evidence-based practice helped in the creation of Republic Act 5680 Otherwise known as the 21ST CENTURY "Philippine Physical Therapy and - APTA adopted Vision 2020, which Occupational Therapy Law" emphasized key areas such as As provided for in this law, a Board autonomous practice, direct access, of Examiners of Physical Therapists the Doctor of Physical Therapy and Occupational Therapists was (DPT) degree, and evidence-based created practice. The first registry and licensing - By 2013, the APTA adopted a new examinations for physical therapists Vision Statement with guiding in the Philippines was given in June principles. addressing areas like 1973 quality, collaboration, innovation, and access, setting the profession BRIEF HISTORY OF PT IN CEBU on a path to meet evolving societal Cebu Doctors' College (now Cebu needs Doctors' University) 1974- PT course was first offered 1908-1909 under Cebu Doctors' CAMS - The earliest recorded information of 1978- first batch graduated historical significance was: 1992- OT was introduced, CDCRS The formation of a Section of was formed Electrotherapeutics, under the Department of Medicine of the Faculty of Medicine PT AS A PROFESSION and surgery of the University Physical Therapy begins with: of Santo Tomas ○ EXAMINATION to determine the nature and status of the 1916 condition - Physiotherapy was included in the ○ EVALUATION to interpret curriculum of the UST Faculty of the findings & establish a Medicine, and Surgery along with diagnosis & prognosis that Radiography led by Dr. Bonito includes a plan of care Valdes ○ INTERVENTIONS are then administered & modified in DECEMBER 08, 1964 accordance with the patient's - The Philippine Physical Therapy responses Association (PPTA) was founded Physical therapy reflects the areas - To promote the professional of prevention and promotion of advancement and provide health, wellness, and fitness continuing educational growth for ROLES IN THE PROVISION OF THE CODE OF ETHICS PHYSICAL THERAPY Principles Core values - Primary role of PT: direct patient care Physical therapists shall Compassion, - Standards of Practice for Physical respect the inherent dignity Integrity and rights of all individuals Therapy by APTA-foundation to the delivery of physical therapy Physical therapists shall be Altruism, trustworthy and Compassion, compassionate in Professional addressing the rights and Duty CONCEPT OF PT PRACTICE needs of patients or clients. EVIDENCED - BASED PRACTICE Physical therapists shall be Excellence, (PRACTICE BASED ON PROOF) accountable for making Integrity - Interventions used in physical sound professional therapy, based on research that judgments. demonstrates the reliability and Physical therapists shall Integrity validity of the procedures. demonstrate integrity in 3 main points their relationships with - Best available evidence patients/clients, families, - Clinical expertise of the provider colleagues, students, - Values & Circumstances of the research participants, other pt/client health care providers, employers, payers, and the TOOLS! public. - PT NOW - PUBMED Physical therapists shall Professional - GOOGLE SCHOLAR fulfill their legal and Duty, professional obligations. Accountability PROFESSIONAL VALUES AND Physical therapists shall Excellence GUIDING DOCUMENTS enhance their expertise Identified and described following through the lifelong the adoption of vision 2020 to acquisition and refinement of knowledge, skills, clearly delineate practice abilities, and professional expectations in the area of behaviors professionalism Physical therapists shall Integrity, CORE VALUES promote organizational Accountability - Accountability behaviors and business practices that benefit - Altruism patients/clients and society - Compassion/caring - Excellence Physical therapists shall Social - Integrity participate in efforts to Responsibility - Professional duty meet the health needs of - Social responsibility people locally, nationally, or globally. LEVEL OF CARE OTHER PROFESSIONAL ROLES OF PT PRIMARY CARE - level of health care delivered by a CONSULTATION member of the health care who is - PI's frequently provide consultation responsible for the majority of the - Purpose is to make health needs of the individual. recommendations concerning the - level of care usually, but not always, is provided by the first health care current or proposed physical provider in contact with the therapy for the patient/client recipient. - Family and community members EDUCATION may also provide care at this level. - PTs and PTAs are continually SECONDARY CARE providing education to a variety of - provided by clinicians on a referral audiences basis-that is, after the individual has - Patients and sometimes family received care at the primary level. members are taught exercises or techniques to enhance function. TERTIARY CARE - PTs and PTAs are involved in - provided by specialists, commonly in facilities that focus on particular academic education. They may health conditions. teach in a formal academic setting - may also be provided on a referral or a continuing education program. basis. CRITICAL INQUIRY - Essential for the viability of the - Entry point for an individual seeking profession. physical therapy services shifting to - Must constantly ask, "Why?" primary care called "DIRECT ACCESS" - "Practice without referral", which ADMINISTRATION implies no regard or interest in the - May move into a variety of critical services provided by administrative positions. practitioners in other disciplines. - An individual could also leave the patient care environment and - PTs are engaged in practice at all three assume an executive position within levels of care. a health care or related organization. - most often delivered by referral as - Responsibilities include planning, secondary or tertiary care. communicating, delegating, - Tertiary care may be provided in a managing, directing, supervising, highly specialized unit, such as a burn budgeting, and evaluating. care center. COLLABORATIVE APPROACH → PHYSICIANS → NURSES → OTS → SLPS  CHAPTER 1 EVIDENCE-BASED PHYSICAL THERAPIST PRACTICE OBJECTIVES Upon completion of this chapter, the student/practitioner will be able to do the following: 1. Discuss the circumstances that have resulted in an emphasis on the use of evidence in practice. 2. Distinguish among definitions of evidence-based medicine, evidence-based practice, and evidence-based physical therapist (EBPT) practice. 3. Discuss the use of evidence in physical therapist decision making in the context of the American Physical Therapy Association’s Guide to Physical Therapist Practice 3.0.1 4. Describe focus areas of EBPT practice. 5. Describe the general steps involved in EBPT practice. 6. Discuss the barriers to EBPT practice and possible strategies for reducing them. TERMS IN THIS CHAPTER Activity limitations (ICF model): “Difficulties an individual may have in executing activities.”2 Biologic plausibility: The reasonable expectation that the human body could behave in the manner predicted. Clinical expertise: Proficiency of clinical skills and abilities, informed by continually expanding knowledge, that individual clinicians develop through experience, learning, and reflection about their practice.3,4 Diagnosis: A process of “integrating and evaluating the data that are obtained during the examination to describe the individual condition in terms that will guide the physical therapist in determining the prognosis and developing a plan of care.”1 Evaluation: The “process by which physical therapists interpret the individual’s response to tests and measures; integrate the test and measure data with other information collected in the history; determine a diagnosis or diagnoses amenable to physical therapist management; determine a prognosis, including goals for physical therapist management; and, develop a plan of care.”1 4 Chapter 1: Evidence-Based Physical Therapist Practice Evidence: “A broad definition of evidence is any empirical observation, whether systematically collected or not. Clinical research evidence refers to the systematic observation of clinical events....”5 Examination: “Physical therapists conduct a history, perform a systems review, and use tests and measures in order to describe and/or quantify an individual’s need for services.”1 Impairment (ICF model): “Problems in body functions or structure such as a significant deviation or loss.”2 Intervention: “Physical therapists purposefully interact with the individual and, when appropriate, with other people involved in his or her care, using various” procedures or techniques “to produce changes in the condition.”1 Outcome: “The actual results of implementing the plan of care that indicate the impact on functioning;” may be measured by the physical therapist or determined by self-report from the patient or client.1 Participation restrictions (ICF model): “Problems an individual may experience in involvement in life situations.”2 Patient-centered care: Health care that “customizes treatment recommendations and decision making in response to patients’ preferences and beliefs.... This partnership also is characterized by informed, shared decision making, development of patient knowledge, skills needed for self-management of illness, and preventive behaviors.”6(p.3) Prevention: “The avoidance, minimization, or delay of the onset of impairment, activity limitations, and/or participation restrictions.”1 Prognosis: “The determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy.”1 Introduction Use of systematically developed evidence in clinical decision making is promoted extensively across health care professions and practice settings. Gordon Guyatt, MD, David L. Sackett, MD, and their re- spective colleagues published the original, definitive works that instruct physicians in the use of clinical research evidence in medical practice.5,7 In addition, federal agencies, including the Agency for Health- care Research and Quality and the Centers for Medicare and Medicaid Services, evaluate the strength of published evidence during the development of clinical guidelines and health care policies.8,9 Profes- sional associations such as the American Medical Association, the American Heart Association, and the American Occupational Therapy Association also have developed resources to help their members and consumers access evidence regarding a wide variety of diseases, treatments, and outcomes.10-12 The physical therapy profession also has expressed a commitment to the development and use of published evidence. The American Physical Therapy Association envisioned that by 2020 physical therapists would be autonomous practitioners who, among other things, used evidence in practice.13 Numerous articles regarding the methods for, benefits of, and barriers to evidence-based practice have been published in the journal Physical Therapy.14-17 For several years, the journal also included a recurring feature, “Evidence in Practice,” in which a patient case was described and the subsequent search for, evaluation, and application of evidence was illustrated.18 The journal also added features  Introduction 5 such as “The Bottom Line” and podcasts in 2006 and 2008, respectively, to facilitate the translation of evidence into practice. Finally, the American Physical Therapy Association has created PTNow, a web-based portal designed to facilitate efficient access to the latest evidence related to physical therapist practice.19 The historical ground swell of interest in the use of evidence in health care resulted from the convergence of multiple issues, including (1) extensive documentation of apparently unexplained practice variation in the management of a variety of conditions, (2) the continued increase in health care costs disproportionate to inflation, (3) publicity surrounding medical errors, (4) identification of potential or actual harm resulting from previously approved medications, and (5) trends in technol- ogy assessment and outcomes research.20-23 In addition, the rapid evolution of Internet technology increased both the dissemination of and access to health care research. Related issues stimulated the drive for EBPT practice, the most dramatic of which was the use of evidence by commercial and government payers as a basis for their coverage decisions. For example, the Centers for Medicare and Medicaid Services ruled that insufficient scientific evidence existed to support the use of transcutaneous electrical stimulation for chronic low back pain and stated that patients must be enrolled in a clinical trial as a condition of coverage for this modality under the Part B benefit.24 In light of these important developments, physical therapists needed an understand- ing of what evidence-based practice is, how it works, and how it may improve their clinical practice. CLINICAL SCENARIO © Photographee.eu/Shutterstock Meet Your Patient Anne is a 41-year-old, right-handed, high school chemistry teacher, and married mother of two boys aged 9 and 11. She presents to your outpatient physical therapy clinic with a 4-week history of progres- sively increasing pain that extends from her right elbow to midway down her lateral forearm. She denies previous injury to this upper extremity but notes that she spent several hours shoveling heavy wet snow from her front walk prior to the onset of her symptoms. Her pain makes it difficult for her to use a keyboard and mouse, grasp and manipulate pens and utensils, and maintain a grip on a full cof- fee mug or glass beaker. She also has discontinued her upper extremity strength training regimen and switched from an elliptical aerobic device to a recumbent cycle ergometer due to her symptoms. She states that ice packs temporarily relieve her pain. She sought physical therapy because her primary care physician recommended anti-inflammatory medication and an orthopedic surgeon recom- mended a corticosteroid injection. She does not want to take medication in any form. She is anxious to resolve this problem as it interferes with her work and daily exercise program. Anne also has many ques- tions about her options and any research available to prove or disprove their usefulness in her case. How will you describe the role of evidence in your clinical decision making? 6 Chapter 1: Evidence-Based Physical Therapist Practice Evidence-Based What? The use of evidence in health care is referred to by a variety of labels with essentially similar mean- ings. Evidence-based medicine, a term relevant to physicians, is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available clinical evidence from systematic research.”3(p.71) “Evidence-based practice” and “evidence-based health care” are labels that have been created to link the behavior described by evidence-based medicine to other health care professionals. Hicks provided this expanded definition: “care that ‘takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.’”25(p.8) In all cases, evidence does not replace clinical expertise; rather, evidence is used to inform more fully a decision-making process in which expertise provides one perspective to the clinical problem. Regardless of the label, the implicit message is that the use of evidence in clinical decision making is a movement away from unquestioning reliance on knowledge gained from authority or tradition. Authority may be attributed to established experts in the field, as well as to revered teachers in professional training programs. Tradition may be thought of as practice habits expressed by the phrase “this is what I have always done for patients like this one.” Habits may be instilled by eminent authority figures, but they also may be based on local or regional practice norms reinforced by their use in payment formulas (“usual and customary”) and in legal proceedings (“local standard of care”). Practice habits also may be reinforced by errors in clinical reasoning related to various biases and the inadequacies of experience-based problem solving, such as those described in Table 1-1.26 TABLE 1-1   Examples of Biases and Heuristic Failures in Clinical Reasoning Type of Clinical Management Reasoning Error Nature of the Problem Consequences Ascertainment Occurs when a clinician draws a The physical therapist forgoes Bias conclusion based on previously held clinical examination proce- expectations of a particular outcome dures that would have identi- (e.g., a physical therapist determines fied joint restrictions in the that a woman is catastrophizing her woman’s lumbar spine. back pain experience because she has expressed job dissatisfaction). Confirmation Bias Occurs when a clinician selectively The physical therapist ap- focuses on information that confirms plies ultrasound to all people a hypothesis (e.g., a physical therapist with adhesive capsulitis of the remembers only those people with shoulder regardless of their re- adhesive capsulitis of the shoulder sponse to the modality. who improved following application of ultrasound and forgets those people who did not improve with the same technique).  Introduction 7 TABLE 1-1   Examples of Biases and Heuristic Failures in Clinical Reasoning (Continued) Type of Clinical Management Reasoning Error Nature of the Problem Consequences Recency Effect Occurs when a clinician believes that The physical therapist classifies a particular patient presentation or all men with generalized pain response is a common phenomenon in the upper back as having because it is easily remembered (e.g., fibromyalgia. a physical therapist believes that fi- bromyalgia is more common in men than in women because her last two patients with this diagnostic label were male). OR Occurs when a clinician believes that The physical therapist mistakes a particular patient presentation or re- pain due to herpes zoster for sponse is an uncommon phenomenon radicular pain due to vertebral because it is not easily remembered joint restriction in a person (e.g., a new graduate physical therapist with an idiopathic acute onset does not remember how to differenti- of symptoms. ate among various sources of painful conditions that express themselves in dermatomal patterns). Representativeness Occurs when a clinician draws conclu- The physical therapist Exclusivity sions about patient presentation or applies the balance program response based only upon those people exactly the same way for all who return for scheduled treatment people with Parkinson’s disease sessions (e.g., a physical therapist who are referred to him for believes all people with Parkinson’s management. disease benefit from a particular bal- ance program based on experience with people who have completed an episode of treatment versus those who have not). Value Bias Occurs when the importance The physical therapist forgoes of an outcome in the eyes of the application of validated clinical clinician distorts the likelihood of the prediction rules and refers all outcome occurring (e.g., a physical people with acute painful con- therapist’s concern about undiagnosed ditions for radiographic testing. fractures in acute painful conditions outweighs the data about prevalence of fractures under specific situations). Modified with permission from John Wiley and Sons. Croskerry P. Achieving quality in clinical decision making: Cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184–1204. 8 Chapter 1: Evidence-Based Physical Therapist Practice Knowledge derived from authority and tradition often reflects an initial understanding of clini- cal phenomena from which diagnostic and treatment approaches are developed based on biologic plausibility and anecdotal experience. As such, this form of knowledge will continue to have a role as new clinical problems are encountered that require new solutions. The fundamental weakness in a clinician’s dependence on this type of knowledge, however, is the potential for selection of ineffective, or even harmful, tests, measures, or interventions as a result of the lack of inquiry into their “true” effects. These cognitive and heuristic failures can lead to incomplete or incorrect conclusions about what is wrong with an individual patient and what is the most effective means for treating the problem. Straus et al. offer as an example the use of hormone replacement therapy in women without a uterus or those who are postmenopausal.27 Women in these situations were observed to have an increased risk of heart disease that, from a biologic perspective, appeared connected to the loss of estrogen and progestin. Replacing the lost hormones in an effort to reduce the risk of heart disease in these women made sense. The success of this treatment was confirmed further by observational studies and small randomized controlled trials.28 However, the early termination in 2002 of a large hormone replacement therapy trial sponsored by the National Institutes of Health challenged the concept of protective effects from this intervention. The study’s initial results indicated, among other things, that estrogen replacement did not protect postmenopausal women against cardio- vascular disease as had been hypothesized. Moreover, long-term estrogen plus progestin therapy increased a woman’s risk for the development of heart attacks, strokes, blood clots, and breast cancer.22 In effect, years of clinical behavior based on a biologically plausible theory supported by lower quality evidence were invalidated by a well-designed piece of evidence. This example is extreme, but it makes the point that health care providers should willingly and knowingly reevalu- ate the assumptions that underlie a practice that is based on authority and tradition supported by limited evidence. Evidence-Based Physical Therapist Practice With that background in mind, this text has adopted the term evidence-based physical therapist (EBPT) practice to narrow the professional and clinical frame of reference. The definition of EBPT should be consistent with previously established concepts regarding the use of evidence, but it also should reflect the specific nature of physical therapist practice. The American Physical Therapy Association’s Guide to Physical Therapist Practice 3.0 describes physical therapy as a profession informed by the World Health Organization’s International Clas- sification of Functioning, Disability, and Health (ICF).1,2 This framework is an expansion of the bio- psychosocial model of health that provides “a means not only to describe the states of illness and disability, but also to classify the components and magnitude of the level of health.”1 The model illustrated in Figure 1-1 depicts the clinical aspects of a patient or client’s situation, as well as the social context that shapes perceptions of health, wellness, illness, and disability for each individual. Within this framework, physical therapists examine, evaluate, diagnose, prognosticate, and intervene with individuals with identified impairments, activity limitations, and participation restrictions, as well as with persons with health, prevention, and wellness needs. These professional behaviors are sum- marized in the term “patient/client management.” Finally, the management process incorporates the individual patient or client as a participant whose knowledge, understanding, goals, preferences, and appraisal of his or her situation are integral to the development and implementation of a physi- cal therapist’s plan of care.  Evidence-Based Physical Therapist Practice 9 FIGURE 1-1   Structure of the ICF model of functioning and disability. Structure of the International Classification of Functioning, Disability and Health (ICF) model of functioning and disability.5 ICF Part 1: Part 2: Functioning Contextual and disability factors Body functions Activities and Environmental Personal and structures participation factors factors Change in Change in Facilitator/ Capacity Performance body function body structure barrier Reprinted from Guide to Physical Therapist Practice 3.0 (http://guidetoptpractice.apta.org), with permission of the American Physical Therapy Association. Copyright © 2006 American Physical Therapy Association. All rights reserved. A definition of EBPT practice that reflects the intent of evidence-based medicine as well as the nature of physical therapist practice is offered here:1,29 Evidence-based physical therapist practice is “open and thoughtful clinical decision making” about physical therapist management of a patient or client that integrates the “best available evidence with clinical judgment” and the patient or client’s preferences and values, and that further considers the larger social context in which physical therapy services are provided, to optimize patient or client outcomes and quality of life. The term “open” implies a process in which the physical therapist is able to articulate in under- standable terms the details of his or her recommendations, including (1) the steps taken to arrive at this conclusion, (2) the underlying rationale, and (3) the potential impact of taking and of refusing action. “Thoughtful clinical decision making” refers to the physical therapist’s appraisal of the risks and benefits of various options within a professional context that includes ethics, standards of care, and legal or regulatory considerations.30 “Best available evidence” refers to timely, well-designed research studies relevant to the question a physical therapist has about a patient or client’s man- agement. “Preferences and values” are the patient or client’s “unique preferences, concerns, and expectations”7 against which each option should be weighed and which ultimately must be reflected in a collaborative decision-making process between the therapist and the patient or client. This point is consistent with the emphasis on patient-centered care as articulated by the Institute of Medicine.6 10 Chapter 1: Evidence-Based Physical Therapist Practice FIGURE 1-2   Evidence-based physical therapist practice in a societal context. Social, Cultural, Economic, and Political Context Published Unpublished Research Evidence Evidence-Based Decision Making Skills Competency Interaction Clinical Patient Expertise Past Experience Beliefs and Values Preferences Expert Knowledge Opinion Reproduced from Evidence-Based Healthcare: A Practical Guide for Therapists, Tracy Bury & Judy Mead, Page 10, Copyright 1999 by Elsevier. Reprinted with permission from Elsevier. Finally, “larger social context” refers to the social, cultural, economic, and political influences that shape health policy, including rules governing the delivery of and payment for health care services.31 Figure 1-2 provides an illustration of EBPT. Evidence-Based Physical Therapist Practice Focus Areas A clinician interested in EBPT practice rightly might ask, “Evidence for what?” The process of patient/ client management provides the answer to this question when one considers its individual elements  Evidence-Based Physical Therapist Practice 11 FIGURE 1-3   The process of physical therapist patient/client management. The process of physical therapist patient and client management. Examination Referral/ Evaluation consultation Diagnosis Prognosis Intervention Outcomes Reprinted from Guide to Physical Therapist Practice 3.0 (http://guidetoptpractice.apta.org), with permission of the American Physical Therapy Association. Copyright © 2006 American Physical Therapy Association. All rights reserved. (Figure 1-3).1 To conduct an examination and evaluation, physical therapists must choose, apply, and interpret findings from a wide variety of tests and measures, such as ligament stress techniques and quantifications of strength and range of motion. Similarly, accurate diagnosis of conditions resulting in pain depends on a properly constructed and tested classification scheme. Well-designed research may assist the physical therapist in selecting the best techniques to correctly identify, quantify, and classify an individual’s problem, a result that will enhance the efficiency and effectiveness of service delivery. Prognosis refers to a prediction of the future status of the patient or client that may reflect the natural course of a condition or result following physical therapy treatments or prevention activities. Predictive ability depends on the physical therapist’s understanding of the phenomenon in question (i.e., accurate diagnosis), as well as the identification of indicators or risk factors that signal a particular direction. In all cases, the therapist must determine which of the numerous characteristics of the individual’s physi- cal, psychological, behavioral, and environmental situation will be most predictive of the outcome of interest. Evidence may identify the most salient factors that will produce the most accurate prediction. 12 Chapter 1: Evidence-Based Physical Therapist Practice The choice of interventions is the step in the patient or client management process that carries particular weight because of the dual responsibilities of the provider to “do good” (beneficence) and to “do no harm” (nonmaleficence). The stakes in this balancing act increase when the intervention in question has a risk of serious consequences, such as permanent disability or mortality. Most treatment options physical therapists implement are not “high risk” in this sense; however, the application of low-risk interventions that produce no positive effect does not meet the test of beneficence. A common clinical scenario is one in which a patient presents with a painful condition and the therapist must decide which manual techniques, exercise, or some combination of both, will be most effective for this individual. Relevant studies may assist the therapist and the patient in a risk–benefit analysis by providing information about effectiveness and harm. The products of the patient or client management process are referred to as the outcomes, which should be distinguished from treatment effects.31 The former focus on results that occurred at the conclusion of the episode of care from the individual’s point of view. For example, return-to-work represents a common outcome following outpatient orthopedic physical therapy management. In contrast, treatment effects represent the change, if any, in the underlying problems that prevented the individual from working. Outcomes usually are stated in functional terms such as “The patient will work 6 hours without pain.” Such statements reflect the individual’s goals for the physical therapy episode of care. Use of measures of standardized outcomes, however, permits an analysis of prog- ress over the course of an episode for a single individual, as well as a comparison across patients or clients with similar issues. As with the selection of tests and measures used to quantify impairments and aid in diagnosis, a physical therapist must decide which instrument of standardized outcomes will provide the most discriminating information with respect to changes in impairment of body functions and structures, activity limitations, participation restrictions, or health-related quality of life. A review of available evidence may assist the therapist to determine what outcomes are pos- sible and which measurement tool is able to detect change in a consistent and meaningful fashion. Evidence also may inform a physical therapist’s understanding of patients’ or clients’ perspectives, beliefs, attitudes, or opinions as they experience health, disease, and/or disability and navigate health care services. The impact of these experiences on their relationships with others, their ability to en- gage in their environment, and their sense of self and relatedness to a larger community also may be relevant to physical therapists’ clinical decision making and anticipated outcomes. A review of studies that capture these experiences through the individual’s own words may facilitate the therapist’s effort to deliver patient-centered care (or “person-centered” services for clients). The Process of Evidence-Based Physical Therapist Practice Evidence-based physical therapist practice as a process starts with a question in response to a patient or client’s problem or concern. A search for relevant studies to answer the question is then followed by a critical appraisal of their merits and conclusions, as well as a determination of their applicability to the individual. At the conclusion of the appraisal, the therapist will consider the evidence in the context of his or her clinical expertise and the individual’s values and preferences during an explicit discussion with that individual.4 Finally, the therapist and that individual will collaborate to identify and implement the next steps in the management process. Evidence-based physical therapist practice depends on a variety of factors. First, physical therapists require sufficient knowledge about their patient or client’s condition to recognize the unknown. In other words, physical therapists must be willing to suspend the assumption that they have complete informa- tion about an individual’s situation. In addition, they must have, or have access to, knowledge of the evidence appraisal process—that is, which features characterize stronger versus weaker study designs. Second, physical therapists need access to the evidence, a situation that has improved considerably with the advent of online databases and electronic publication of journals. Availability of these resources, however, does not ensure their efficient use, particularly when it comes to developing effective search  Evidence-Based Physical Therapist Practice 13 strategies. Third, physical therapists need the time to search for, appraise, and integrate the evidence into their practice. In busy clinical settings, time is a limited commodity that usually is dedicated to administrative tasks, such as documentation of services and discussions with referral sources and pay- ers. Unless the entire clinic or department adopts the EBPT philosophy, it may be difficult for a single physical therapist to incorporate the behavior into his or her patient or client management routine. Results from a survey conducted by Jette et al. in 2003 suggested that some of the requirements of EBPT practice are obstacles to its implementation.16 Although most respondents (n = 488) believed evidence was necessary for practice and improved quality of care, 67% of the subjects listed “lack of time” as one of the top three barriers to implementation of EBPT practice. Nearly all respondents (96%) indicated they had access to evidence; however, 65% reported performing searches for clinical studies less than twice in a typical month. In addition, notable proportions of the sample indicated lower confidence levels in their abilities to search effectively (34%), appraise the study designs (44%), and interpret results using terms such as “odds ratio” (47%) and “confidence interval” (37%). Finally, older therapists with more years since licensure were less likely to have the necessary training, familiarity with, and confidence in the skills necessary for effective EBPT practice. Subsequent studies have suggested an overall improvement in physical therapists’ knowledge of and self-efficacy with evidence-based practice skills. However, changes in clinical decision making in response to available evidence continue to lag.32-34 This disparity between EBPT knowledge and actual practice fuels the current interest in knowledge translation methods.34-38 Jones et al. published a systematic review of the evidence regarding knowledge translation interventions in rehabilitation.35 Thirteen of the articles included in the review were specific to physical therapist practice. All of these studies included some form of professional education regarding EBPT practice. Only two included audit and feedback mechanisms to study participants. Results were mixed, a finding Jones and col- leagues attributed to the low methodological quality of most of the studies. Clearly, more work is needed to close the gap between the EBPT knowledge and skills acquired in professional physical therapist education and their application in clinical practice. So, what can be done to reduce the barriers to effective EBPT practice? Perhaps most importantly, a philosophical shift is required to develop consistent behavior during a busy day of patient or client care. Physical therapists must value the contribution trustworthy evidence can make when integrated with clinical judgment and a patient or client’s values and preferences. Management support also is necessary in terms of EBPT education, access to evidence, time allotted in a therapist’s schedule, and ongoing feedback about the impact evidence has on patient or client outcomes. Use of services that locate, summarize, and appraise the evidence for easy review by practitioners may also help the time issue. However, physical therapists must determine whether the methodology used by these services is sufficiently stringent to provide an appropriate assessment of evidence quality. Databases dedicated to physical therapy evidence also may enhance the efficiency of the search process. Ultimately, the ability to engage in EBPT practice consistently requires practice, just like any other skill. The process starts with the individual patient or client and the questions generated from the initial encounter, such as the following: Which tests will provide accurate classification of this person’s problem? What activity limitations can be anticipated if this problem is not addressed? What is the most effective intervention that can be offered for documented impairments in body functions and structure? How will we know if we have been successful? How can changes in this person’s quality of life that result from this episode of care be captured? Can the perspectives of other people who have similar issues or concerns inform my decision making for this individual? 14 Chapter 1: Evidence-Based Physical Therapist Practice A physical therapist’s willingness to consider these questions consciously is the first step in EBPT practice. The word “consciously” is emphasized because it takes practice to develop the habit of openly challenging one’s assumptions and current state of knowledge. Until this behavior becomes a routine part of one’s practice, EBPT practice will be difficult to implement in a consistent and time-efficient manner. Summary The use of systematically developed evidence in clinical decision making is promoted among many health professions in response to documented practice variation and increasing health care costs, as well as in response to a desire for improved quality of care. Evidence-based practice in any profession promotes less dependence on knowledge derived from authority or tradition through the use of evidence to evalu- ate previously unquestioned information. EBPT practice is open, thoughtful decision making about the physical therapist management of a patient or client that integrates the best available evidence, clinical expertise, and the patient or client’s preferences and values, within the larger social context of the indi- vidual and the therapist. Well-designed research studies may inform decision making regarding measure- ment, diagnosis, prognosis, interventions, and outcomes, as well as the perspectives and experiences of individuals seeking physical therapist services. Requirements for EBPT practice include a willingness to challenge one’s assumptions, the ability to develop relevant clinical questions about a patient or client, access to evidence, knowledge regarding evidence appraisal, and the time to make it all happen, as well as a willingness to acquire, practice, and evaluate the impact of the necessary skills described in this text. Exercises 1. Describe two factors that have prompted the emphasis on evidence-based practice in health care. How might evidence address these issues or concerns? 2. Discuss the strengths and weaknesses of clinical knowledge derived from the following: a. Authority b. Evidence c. Tradition 3. Describe a specific example in current physical therapist practice of each type of knowledge listed in question #2. 4. Use Anne’s case history and provide examples for each of the potential errors in clinical reasoning described in Table 1-1. 5. Discuss the potential contribution of evidence to each step of the patient or client management process. Provide clinical examples relevant to physical therapist practice to support your points. 6. Discuss the role of the patient or client in EBPT practice. Provide a clinical example relevant to physical therapist practice to support your points. 7. Think about your experiences in the clinical setting and complete the survey in Figure 1-4 modified from Jette et al.16 What do your answers tell you about your willingness and readiness to participate in EBPT practice? 8. Based on your results from the previous question, identify two changes you would need to make to enhance your ability to participate in EBPT practice. For each change, identify one strategy you could implement to move you in the right direction.  Summary 15 FIGURE 1-4   Survey of beliefs and attitudes regarding evidence-based physical therapist practice. Appendix. Evidence-Based Practice (EBP) Questionnaire This section of the questionnaire inquires about personal attitudes toward, use of, and perceived benefits and limitations of EBP. For the following items, place a mark x in the appropriate box that indicates your response. 1. Application of EBP is necessary in the practice of physical therapy. Strongly disagree Disagree Neutral Agree Strongly Agree 2. Literature and research findings are useful in my day-to-day practice. Strongly disagree Disagree Neutral Agree Strongly Agree 3. I need to increase the use of evidence in my daily practice. Strongly disagree Disagree Neutral Agree Strongly Agree 4. The adoption of EBP places an unreasonable demand on physical therapists. Strongly disagree Disagree Neutral Agree Strongly Agree 5. I am interested in learning or improving the skills necessary to incorporate EBP into my practice. Strongly disagree Disagree Neutral Agree Strongly Agree 6. EBP improves the quality of patient care. Strongly disagree Disagree Neutral Agree Strongly Agree 7. EBP does not take into account the limitations of my clinical practice setting. Strongly disagree Disagree Neutral Agree Strongly Agree 8. My reimbursement rate will increase if I incorporate EBP into my practice. Strongly disagree Disagree Neutral Agree Strongly Agree 9. Strong evidence is lacking to support most of the interventions I use with my patients. Strongly disagree Disagree Neutral Agree Strongly Agree 10. EBP helps me make decisions about patient care. Strongly disagree Disagree Neutral Agree Strongly Agree 11. EBP does not take into account patient preferences. Strongly disagree Disagree Neutral Agree Strongly Agree For the following items, place a mark x in the appropriate box that indicates your response for a typical month. 12. Read/review research/literature related to my clinical practice. ≤ 1 article 2-5 articles 6-10 articles 11-15 articles 16+ articles 13. Use professional literature and research findings in the process of clinical decision making. ≤ 1 time 2-5 times 6-10 times 11-15 times 16+ times 14. Use MEDLINE or other databases to search for practice-relevant literature/research. ≤ 1 time 2-5 times 6-10 times 11-15 times 16+ times The following section inquires about personal use and understanding of clinical practice guidelines. Practice guidelines provide a description of standard specifications for care of patients with specific diseases and are developed through a formal, consensus-building process that incorporates the best scientific evidence of effectiveness and expert opinion available. For the following items, place a mark x in the appropriate box that indicates your response. 15. Practice guidelines are available for topics related to my practice. Yes No Do Not Know 16. I actively seek practice guidelines pertaining to areas of my practice. Strongly disagree Disagree Neutral Agree Strongly Agree 17. I use practice guidelines in my practice. Strongly disagree Disagree Neutral Agree Strongly Agree 18. I am aware that practice guidelines are available online. Yes No 19. I am able to access practice guidelines online. Yes No 20. I am able to incorporate patient preferences with practice guidelines. Strongly disagree Disagree Neutral Agree Strongly Agree The following section inquires about availability of resources to access information and personal skills in using those resources. For the following items, place a mark x in the appropriate box that indicates your response. In items referring to your "facility," consider the practice setting in which you do the majority of your clinical care. 21. I have access to current research through professional journals in their paper form. Yes No 22. I have the ability to access relevant databases and the Internet at my facility. Yes No Do Not Know (continues) 16 Chapter 1: Evidence-Based Physical Therapist Practice FIGURE 1-4   Survey of beliefs and attitudes regarding evidence-based physical therapist practice. (Continued) 23. I have the ability to access relevant databases and the Internet at home or locations other than my facility. Yes No Do Not Know Agree Strongly Agree 24. My facility supports the use of current research in practice. Strongly disagree Disagree Neutral Agree Strongly Agree 25. I learned the foundations for EBP as part of my academic preparation. Strongly disagree Disagree Neutral Agree Strongly Agree 26. I have received formal training in search strategies for finding research relevant to my practice. Strongly disagree Disagree Neutral Agree Strongly Agree 27. I am familiar with the medical search engines (e.g., MEDLINE, CINAHL). Strongly disagree Disagree Neutral Agree Strongly Agree 28. I received formal training in critical appraisal of research literature as part of my academic preparation. Strongly disagree Disagree Neutral Agree Strongly Agree 29. I am confident in my ability to critically review professional literature. Strongly disagree Disagree Neutral Agree Strongly Agree 30. I am confident in my ability to find relevant research to answer my clinical questions. Strongly disagree Disagree Neutral Agree Strongly Agree For the following item, place a mark x in one box in the row for each term. 31. My understanding of the following terms is: Understand Understand Do Not Term Completely Somewhat Understand a) Relative risk b) Absolute risk c) Systematic review d) Odds ratio e) Meta-analysis f) Confidence interval g) Heterogeneity h) Publication bias For the following items, rank your top 3 choices by placing number in the appropriate boxes (1 = most important). 32. Rank your 3 greatest barriers to the use of EBP in your clinical practice. Insufficient time Lack of information resources Lack of research skills Poor ability to critically appraise the literature Lack of generalizability of the literature findings to my patient population Inability to apply research findings to individual patients with unique characteristics Lack of understanding of statistical analysis Lack of collective support among my colleagues in my facility Lack of interest Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003; 83(9):786–805. Reprinted with permission of the American Physical Therapy Association. Copyright © 2003. American Physical Therapy Association.  References 17 References 1. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. Available at: http://guide toptpractice.apta.org. Accessed July 16, 2016. 2. World Health Organization. Towards a Common Language of Functioning, Disability and Health. ICF. Geneva, Switzerland: World Health Organization; 2002. Available at: http://www.who.int/classifications/icf/icfbeginners guide.pdf. Accessed July 16, 2016. 3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71–72. 4. Higgs J, Jones M, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. 3rd ed. Oxford, England: Butterworth-Heinemann; 2008. 5. Guyatt G, Rennie D. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 3rd ed. Chicago, IL: AMA Press; 2014. 6. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Institute of Medicine Website. Available at: https://www.nap.edu/read/10681/chapter/1. Accessed July 16, 2016. 7. Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 2000. 8. EPC Evidence-based Reports. Agency for Healthcare Research and Quality Website. Available at: http://www.ahrq.gov/research/findings/evidence-based-reports/index.html. Accessed July 16, 2016. 9. Medicare Evidence Development and Coverage Advisory Committee. Centers for Medicare and Medicaid Services Website. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/FACA/MEDCAC.html. Accessed July 16, 2016. 10. JAMA evidence. American Medical Association Website. Available at: http://jamaevidence.mhmedical.com. Accessed July 16, 2016. 11. Process for Evidence Evaluation. American Heart Association Website. Available at: http://cpr.heart.org/AHAECC/CPRAndECC/ResuscitationScience/InternationalLiaisonCommitteeonResuscitationILCOR /UCM_476509_Process-for-Evidence-Evaluation.jsp. Accessed July 16, 2016. 12. Evidence-based Practice & Research. American Occupational Therapy Association Website. Available at: http://www.aota.org/Practice/Researchers.aspx. Accessed July 16, 2016. 13. Vision 2020. American Physical Therapy Association Website. Available at: www.apta.org/Vision2020/. Accessed July 16, 2016. 14. Schreiber J, Stern P, Marchetti G, Providence I. Strategies to promote evidence-based practice in pediatric physical therapy: a formative evaluation project. Phys Ther. 2009;89(9):918­–933. 15. Stevans JM, Bise CG, McGee JC, et al. Evidence-based practice implementation: case report of the evolution of a quality improvement program in a multicenter physical therapy organization. Phys Ther. 2015:95(4):588–599. 16. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786–805. 17. Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87(10):1284–1303. 18. Rothstein JM. Editors Notes. Phys Ther. 2002;82. Physical Therapy Journal Website. Available at: http://ptjournal. apta.org/content/82/1/6.full. Accessed July 16, 2016. 19. PTNow. American Physical Therapy Association Website. Available at: www.ptnow.org/Default.aspx. Accessed July 16, 2016. 20. Eddy DM. Evidence-based medicine: a unified approach. Health Affairs. 2005;24(1):9–17. 21. Steinberg EP, Luce BR. Evidence based? Caveat emptor! Health Affairs. 2005;24(1):80–92. 22. Women’s Health Initiative Participant Information. Women’s Health Initiative Website. Available at: https:// www.nhlbi.nih.gov/whi/. Accessed July 16, 2016. 18 Chapter 1: Evidence-Based Physical Therapist Practice 23. The National Academies of Sciences, Engineering, Medicine Website. Available at: https://www.national academies.org/hmd/. Accessed July 16, 2016. 24. CMS Retains Clinical Study Requirement in Final TENS Decision Memo. American Physical Therapy Associa- tion Website. Available at: www.apta.org/PTinMotion/NewsNow/2012/6/12/FinalTENSMemo/. Accessed July 16, 2016. 25. Hicks N. Evidence-based healthcare. Bandolier. 1997;4(39):8. 26. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184–1204. 27. Straus SE, Richardson WS, Glaziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. Edinburgh, Scotland: Elsevier Churchill Livingstone; 2005. 28. Mobasseri S, Liebson PR, Klein LW. Hormone therapy and selective receptor modulators for prevention of coronary heart disease in postmenopausal women: estrogen replacement from the cardiologist’s perspective. Cardiol Rev. 2004;12(6):287–298. 29. American Physical Therapy Association. Normative Model of Physical Therapist Education: Version 2004. Alexandria, VA; 2004. 30. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users’ Guides to patient care. Evidence-Based Medicine Working Group. JAMA. 2000;284(10):1290–1296. 31. Herbert R, Jamtvedt G, Hagen KB, Mead J. Practical Evidence-Based Physiotherapy. 2nd ed. Edinburgh, Scotland: Elsevier Butterworth-Heinemann; 2011. 32. Manns PJ, Norton AV, Darrah J. Cross-sectional study to examine evidence-based practice skills and behaviors of physical therapy graduates: is there a knowledge-to-practice gap? Phys Ther. 2015;95(4):568–578. 33. Olsen NR, Bradley P, Lomborg K, Nortvedt NW. Evidence-based practice in clinical physiotherapy education: a qualitative interpretive discussion. BMC Med Educ. 2013;13:52. 34. Tilson JK, Mickan S, Howard R et al. Promoting physical therapists’ use of research evidence to inform clini- cal practice: part 3 – long term feasibility assessment of the PEAK program. BMC Med Educ. 2016;16(1):144. 35. Jones CA, Roop SC, Pohar SL, Albrecht L, Scott SD. Translating knowledge in rehabilitation: a systematic review. Phys Ther. 2015;95(4):663–677. 36. Deutsch JE, Romney W, Reynolds J, Manal TJ. Validity and usability of a professional association’s web-based knowledge translation portal: American Physical Therapy Association’s PTNow.org. BMC Med Inform Decis Mak. 2015;15:79. 37. Hudon A, Gervais M-J, Hunt M. The contribution of conceptual frameworks to knowledge translation interven- tions in physical therapy. Phys Ther. 2015;95(4):630–639. 38. Schreiber J, Marchetti GF, Racicot B, Kaminski E. The use of a knowledge translation program to increase the use of standardized outcome measures in an outpatient pediatric physical therapy clinic: administrative case report. Phys Ther. 2015;95(4):613–629.  CHAPTER 2 WHAT IS EVIDENCE? OBJECTIVES Upon completion of this chapter, the student/practitioner will be able to do the following: 1. Discuss the concept of “best available clinical evidence.” 2. Describe the general content and procedural characteristics of desirable evidence and their implications for the selection of studies to evaluate. 3. Describe different forms of evidence and their uses for answering clinical questions in physical therapist practice. 4. Discuss and apply the principles and purposes of evidence hierarchies for each type of clinical question. 5. Discuss the limitations of evidence hierarchies and their implications for the use of evidence in practice. TERMS IN THIS CHAPTER Bias: Results or inferences that systematically deviate from the truth “or the processes leading to such deviation.”1(p.251) Biologic plausibility: The reasonable expectation that the human body could behave in the manner predicted. Case report: A detailed description of the management of a patient or client that may serve as a basis for future research,2 and describes the overall management of an unusual case or a condition that is infrequently encountered in practice or poorly described in the literature.3 Clinical practice guidelines: “... statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harm of alternative care options.”4 also referred to as “summaries.”5 Cross-sectional study: A study that collects data about a phenomenon during a single point in time or once within a single defined time interval.6 Effectiveness: The extent to which an intervention or service produces a desired outcome under usual clinical conditions.1 20 Chapter 2: What Is Evidence? Efficacy: The extent to which an intervention or service produces a desired outcome under ideal conditions.1 Evidence: “A broad definition of evidence is any empirical observation, whether systematically collected or not. Clinical research evidence refers to the systematic observation of clinical events....”7 Experimental design: A research design in which the behavior of randomly assigned groups of subjects is measured following the purposeful manipulation of an independent variable(s) in at least one of the groups; used to examine cause and effect relationships between an independent variable(s) and an outcome(s).8,9 Longitudinal study: A study that looks at a phenomenon occurring over an extended period of time.1 Narrative review (also referred to as a literature review): A description of prior research without a systematic search and selection strategy or critical appraisal of the studies’ merits.10 Nonexperimental design (also referred to as an observational study): A study in which controlled manipulation of the subjects is lacking8; in addition, if groups are present, assignment is predetermined based on naturally occurring subject characteristics or activities.6 Peer review: A process by which research is appraised by one or more content experts; commonly utilized when articles are submitted to journals for publication and when grant proposals are submitted for funding.1 Physiologic study: A study that focuses on the cellular or physiologic systems levels of the subjects; often performed in a laboratory.6 Prospective design: A research design that follows subjects forward over a specified period of time. Quasi-experimental design: A research design in which there is only one subject group or in which randomization to more than one subject group is lacking; controlled manipulation of the subjects is preserved.11 Randomized clinical trial (also referred to as a randomized controlled trial and a randomized controlled clinical trial) [RCT]: A clinical study that uses a randomization process to assign subjects to either an experimental group(s) or a control (or comparison) group. Subjects in the experimental group receive the intervention or preventive measure of interest and then are compared to the subjects in the control (or comparison) group who did not receive the experimental manipulation.8 Retrospective design: A research design that uses historical (past) data from sources such as medical records, insurance claims, or outcomes databases. Single-system design: A quasi-experimental research design in which one subject receives in an alternating fashion both the experimental and control (or comparison) condition.8 Synopsis: “A succinct description of selected individual studies or systematic reviews.”5 Systematic review: A method by which a collection of individual research studies is gathered and critically appraised in an effort to reach an unbiased conclusion about the cumulative weight of the evidence on a particular topic6; also referred to as “syntheses.”5 Systems: “Individual patient characteristics are automatically linked to the current best evidence that matches the patient’s specific circumstances and the clinician is provided with key aspects of management (e.g., computerized decision support systems).”5  General Characteristics of Desirable Evidence 21 CLINICAL SCENARIO © Photographee.eu/Shutterstock Relevant Patient Characteristics Anne’s case history contains information about her that may ­influence your search for evidence and your judgment about its ­relevance. Examples include age and fitness level. What other ­characteristics can you identify that may influence your search for and application of evidence in Anne’s situation? Introduction The case has been made that physical therapists should use evidence to inform their decision mak- ing during the patient/client management process. This claim raises the question “What qualifies as evidence?” In their original work, Guyatt and Rennie stated, “any empirical observation about the apparent relation between events constitutes potential evidence.”7 This observation acknowledged that a variety of information types exist that may be integrated with clinical decisions. Options include, but are not limited to, published research articles, clinical practice guidelines, patient or client records, and recall of prior patient or client cases. As these authors acknowledged, however, clinical research is the preferred source of information. Sackett et al. put a finer point on it with their use of the modifier “best available” clinical evidence. They proposed that a method of prioritizing the evidence according to its merits is required to guide the clinician’s selection of relevant infor­ mation.12 This chapter discusses the forms and general characteristics of evidence available, as well as the hierarchies that have been developed to rank them. General Characteristics of Desirable Evidence In light of the variety of evidence potentially available to physical therapists, it is helpful to have some general characteristics to consider during the initial search. Desirable attributes relate both to content as well as to procedural considerations that serve as preliminary indicators of quality. The first content criterion pertains to the type of question a physical therapist wants to answer. The patient/client management elements of examination, diagnosis, prognosis, intervention (including preventive measures), and outcomes provide potential focus areas for evidence development and application. Ideally, the evidence located will address specifically the test, measure, classification system, prognostic factor, treatment technique, clinical prediction rule, or outcome that the physical therapist is considering relative to an individual patient or client. The second content criterion pertains to the individuals studied. Desirable evidence includes subjects whose personal and/or clinical characteristics are similar to the patient or client in order to increase the therapist’s ability to apply the research findings to this individual. Common attributes 22 Chapter 2: What Is Evidence? of interest include, but are not limited to, the subjects’ age, gender, race/ethnicity, education level, occupation, diagnosis(es), stage of illness, duration of the problem(s), functional status, level of dis- ability, and clinical setting in which patient/client management occurs. Subjects in a research study whose personal and/or clinical characteristics differ markedly from those of a patient or client may have different therapeutic experiences than can be achieved by the individual with whom the physical therapist wishes to use the evidence located. Two basic procedural characteristics have relevance in the evidence selection process as well. The period in time during which the evidence was developed is often of interest given the rapid evo- lution of medical technology and pharmaceutical agents. This is particularly relevant for research publications given that articles often appear in journals a year or more after the completion of the project.7 Early release on the Internet ahead of the printed version undoubtedly has reduced this time line in many cases. Nevertheless, older evidence may not reflect current patient management. A hypothetical example might be a 15-year-old study evaluating the effectiveness of an aerobic train- ing program for individuals with multiple sclerosis that has limited relevance now that a variety of disease-modifying drugs are available.13 However, evidence should not be rejected only because of its age if the techniques in question, and the context in which they were evaluated, have remained relatively unchanged since the data were collected. A procedural characteristic specific to scientific journals is the application of peer review. Peer review is the process by which manuscripts are evaluated by identified content experts to determine their merit for publication. Evaluation criteria usually include the credibility of a research study in terms of its design and execution, relevance of the findings for the field and/or the specific journal, contribution to the body of knowledge about the topic, and, to a lesser degree, writing style.1 Peer review acts as an initial screening process to weed out lower quality efforts. Table 2-1 summarizes the four general characteristics of evidence that are preferable. Note that these attributes are labeled “desirable,” not “mandatory.” This word choice is purposeful because there is much work to be done to expand the depth and breadth of evidence related to physical therapist practice. Many of the clinical questions physical therapists have about their patients or clients have not been explored or have been addressed in a limited fashion. A search for the “best available clini- cal evidence” may result in the identification of studies that are not peer reviewed or do not include subjects that look like a therapist’s individual patient or client. Similarly, studies may not exist that include a test or technique of interest in the clinical setting. The evidence-based physical therapist (EBPT) practice challenge is to decide whether and how to use evidence that is limited in these ways when it is the only evidence available. TABLE 2-1   Four Desirable Characteristics of Research Identified During a Search for Evidence 1. The evidence addresses the specific clinical question the physical therapist is trying to answer. 2. The subjects studied have characteristics similar to the patient or client about whom the physical therapist has a clinical question. 3. The context of the evidence and/or the technique of interest are consistent with contempo- rary health care. 4. The evidence was published in a peer-reviewed medium (paper, electronic).  Forms of Evidence 23 Forms of Evidence As noted previously, forms of evidence may include anything from patient records and clinical re- call to published research. Evidence-based practice in health care emphasizes the use of research to inform clinical decisions because of the systematic way in which data are gathered and because of its potential to provide objective results that minimize bias. A variety of research design options exist. A key point is that different research designs are suited to answering different types of clinical questions therapists may have about their patients or clients. The usefulness of a diagnostic test must be evaluated with methods that are different from those used to determine whether an intervention works. As a result, therapists should anticipate looking for evidence with different research designs depending on what they want to know. The remainder of this chapter provides highlights of these different designs and their relative merits. Research Designs: Overview Forms of evidence fall along a continuum that is dictated by the presence and strength of a research design that was established prior to data collection (Figure 2-1). At one end of the continuum is research that attempts to impose maximum control within the design in order to reduce the chance that bias will influence the study’s results. Bias is a systematic deviation from the truth that occurs as a result of uncontrolled (and unwanted) influences during the study.1 Various authors refer to research designs with the best features to minimize bias as randomized clinical trials, randomized controlled tri- als, or randomized controlled clinical trials.1,6,8 The acronym used for all three is “RCT.” These studies also are categorized as experimental designs. Irrespective of the label, the researchers’ intention is the same: to reduce unwanted influences in the study through random assignment of study participants to two or more groups and through controlled manipulation of the experimental intervention. A variant of this approach is the single-system design in which only one person is studied who receives, on an alternating basis, both the experimental and control (or comparison) conditions.8 An RCT or single-system design is best suited to answer questions about whether an experimental intervention has an effect and whether that effect is beneficial or harmful to the subjects. When con- ducted under ideal conditions—that is, when a high degree of control is achieved—these studies are focused on treatment efficacy. An example might be a study in which some individuals with traumatic brain injuries are randomized to an experimental balance-training program that is performed in a quiet research laboratory. Such an environment is free of distractions that may interfere with their ability to pay attention to directions and focus on the required activities. Alternatively, if the same subjects perform the experimental balance-training program during their regular physical therapy appointment FIGURE 2-1   Continuum of bias control in research designs. Most bias control Least bias control Experimental Quasi-Experimental Nonexperimental Case Report/ Designs Designs Designs Anecdote 24 Chapter 2: What Is Evidence? in the outpatient rehabilitation center, then the RCT is focused on treatment effectiveness.14 Investi- gators in this version of the study want to know if the balance program works in a natural clinical environment full of noise and activity. Randomized clinical trials and single-system designs are approaches used to conduct an original research project focusing on one or more persons. These individual studies themselves may serve as the focus of another type of controlled research design referred to as a systematic review. Systematic reviews, or “syntheses,” comprise original evidence that has been selected and critically appraised according to pre-established criteria.6 The goal of this research design is to draw conclusions from the cumulative weight of studies that, individually, may not be sufficient to provide a definitive answer. The pre-established criteria are used to minimize bias that may be introduced when investigators make decisions about which prior studies to include and when judgments are made about their quality. Systematic reviews may address any type of clinical question; however, most commonly they focus on well-controlled studies of interventions—in other words, on RCTs. At the other end of the evidence continuum is the unsystematic collection of patient or client data that occurs in daily physical therapist practice. The term unsystematic is not meant to imply substandard care; rather, it is an indication that clinical practice is focused on the individual patient or client rather than on groups of subjects on whom behavioral and data collection controls are imposed to ensure research integrity. This type of evidence often is labeled “anecdotal”11 and frequently put to use when therapists recall from memory prior experiences with patients or clients similar to the person with whom they are currently dealing. In response to regulatory and payment pressures, many clinical settings are creating a degree of consistency in data collection with their implementation of standardized assessment and outcomes instruments, electronic health records, and databases to capture patient or client outcomes. As a result, physical therapists working in these settings may find some evidence that is useful to inform their practice. In between the two ends of the evidence continuum are study designs that lack one or more of the following characteristics: 1. Randomization techniques to distribute subjects into groups; 2. The use of more than one group in order to make a comparison; 3. Controlled experimental manipulation of the subjects; 4. Measures at the patient or client level (e.g., impairment in body functions and structure, activity limitations, participation restrictions); and/or 5. A systematic method for collecting and analyzing information. These designs have fewer features with which to minimize bias and/or shift their focus away from patient- or client-centered outcomes. For example, quasi-experimental designs maintain the purposeful manipulation of the experimental technique, but they may not randomize subjects to groups or may have only one subject group to evaluate.11 Nonexperimental (or observational) designs have even less control than quasi-experimental studies because they have the same limitations with respect to their group(s) and they do not include experimental manipulation of subjects.8 In spite of their less rigorous designs, both quasi-experimental and nonexperimental studies are used to evaluate the effectiveness of interventions, often due to ethical or pragmatic reasons related to the use of patients in research. In addition, observational designs are used to answer questions about diagnostic tests, clinical measures, prognostic indicators, clinical prediction rules, and patient or client outcomes. Below quasi-experimental and nonexperimental designs on the continuum are research efforts that focus only on cellular, anatomic, or physiologic systems. These studies often have a high degree of control because they are grounded in the scientific method that is the hallmark of good bench research. They are lower on the continuum not because of their potential for bias, but because they do not focus on person-level function. For this reason, they are referred to as physiologic studies.7  Forms of Evidence 25 Even lower on the continuum are case reports and narrative reviews. These study approaches have different purposes. Case reports simply describe what occurred with a patient or client, whereas narrative reviews summarize prior research.2,3,10 In spite of these differences, these designs have one common element that puts them both at the bottom of the continuum: they lack the kind of systematic approach necessary to reduce bias. It is important to note, however, that the content of a case report or narrative review may provide a stimulus to conduct a more rigorous research project. Table 2-2 provides a list of citations from physical therapy literature that represent each type of study design described here. Research Designs: Timing Research designs also may be categorized according to the time line used in the study. For example, physical therapist researchers may want to know the relationship between the number of visits to an outpatient orthopedic clinic and the workers’ compensation insurance status of patients treated over a 3-year period. Such a question may be answered through an analysis of 3 years of historical patient records from the clinic. This retrospective design has as an opposite form—a prospective design—in which the investigators collect information from new patients that are admitted to the clinic. As Figure 2-2 TABLE 2-2   Citations from Physical Therapy Research Illustrating Different Study Designs Study Design Citation Systemic Review Vanti C, et al. Effect of taping on spinal pain and disability: syste­ matic review and meta-analysis of randomized trials. Phys Ther. 2015;95(4):493–506. Randomized Clinical Fox EE, et al. Effect of Pilates-based core stability training on ambu- Trial lant people with multiple sclerosis: multi-center, assessor blinded randomized controlled trial. Phys Ther. 2016;96(8):1170–1178. Single-System Design Chen YP, et al. Use of virtual reality to improve upper-extremity control in children with cerebral palsy: a single subject design. Phys Ther. 2007;87(11):1441–1457. Quasi-Experimental Drolett A, et al. Move to improve: the feasibility of using an early Study mobility protocol to increase ambulation in the intensive and inter- mediate care settings. Phys Ther. 2013;93(2):197–207. Observational Study Farley MK, et al. Clinical markers of the intensity of balance chal- lenge: observational study of older adult responses to balance tasks. Phys Ther. 2016;96(3):313–323. Physiologic Study Chung JI, et al. Effect of continuous-wave low-intensity ultrasound in inflammatory resolution of arthritis-associated synovitis. Phys Ther. 2016;96(6):808–817. Case Report Parkitny L, et al. Interdisciplinary management of complex regional pain syndrome of the face. Phys Ther. 2016;96(7):1067–1073. Summary Barr AE, et al. Pathophysiologic tissue changes associated with repetitive movement: a review of the evidence. Phys Ther. 2002;82(2):173–187. 26 Chapter 2: What Is Evidence? FIGURE 2-2   Graphic depiction of retrospective and prospective research designs. PAST Retrospective Design TODAY Data available from historical records TODAY Prospective Design FUTURE Data collected in real time illustrates, a retrospective approach takes advantage of data that already exist, whereas a prospective approach requires that new data be collected in real time. In a similar fashion, researchers may be interested in a single point in time or a limited time in- terval (e.g., cross-sectional study), or they may wish to study a phenomenon over an extended period of time (e.g., longitudinal study). In the cross-sectional approach, investigators may have an interest in the functional outcome at discharge (a single point in time) from the hospital of patients receiving physical therapist services following total hip replacement. In contrast, a longitudinal approach would include follow-up of these patients to assess outcomes at discharge and at a specified point or points in time in the future (e.g., 3 months, 6 months, 1 year). Figure 2-3 illustrates these design options. The sequence of events across time in a study is important, particularly when an investigator is trying to determine whether a change in the patient or client’s condition was the direct result of the intervention or preventive measure applied. Specifically, the intervention must have occurred before the outcome was measured to increase one’s confidence that it was the technique of interest that made a difference in the subject’s status or performance. Research Designs: What Is the Question? Remember that the clinical question the physical th